title: Emergency department crowding and decreased quality of pain care.
abstract: OBJECTIVE
  The objective of this study was to evaluate the association of emergency department (ED) crowding factors with the quality of pain care.
  
  
  METHODS
  This was a retrospective observational study of all adult patients (> or =18 years) with conditions warranting pain care seen at an academic, urban, tertiary care ED from July 1 to July 31, 2005, and December 1 to December 31, 2005. Patients were included if they presented with a chief complaint of pain and a final ED diagnosis of a painful condition. Predictor ED crowding variables studied were 1) census, 2) number of admitted patients waiting for inpatient beds (boarders), and 3) number of boarders divided by ED census (boarding burden). The outcomes of interest were process of pain care measures: documentation of clinician pain assessment, medications ordered, and times of activities (e.g., arrival, assessment, ordering of medications).
  
  
  RESULTS
  A total of 1,068 patient visits were reviewed. Fewer patients received analgesic medication during periods of high census (>50th percentile; parameter estimate = -0.47; 95% confidence interval [CI] = -0.80 to -0.07). There was a direct correlation with total ED census and increased time to pain assessment (Spearman r = 0.33, p < 0.0001), time to analgesic medication ordering (r = 0.22, p < 0.0001), and time to analgesic medication administration (r = 0.25, p < 0.0001). There were significant delays (>1 hour) for pain assessment and the ordering and administration of analgesic medication during periods of high ED census and number of boarders, but not with boarding burden.
  
  
  CONCLUSIONS
  ED crowding as measured by patient volume negatively impacts patient care. Greater numbers of patients in the ED, whether as total census or number of boarders, were associated with worse pain care.
authors.affiliation: Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY, USA. ula.hwang@mountsinai.org
authors.forename: Ula
authors.initials: U
authors.lastname: Hwang
authors.forename: Lynne
authors.initials: L
authors.lastname: Richardson
authors.forename: Elayne
authors.initials: E
authors.lastname: Livote
authors.forename: Ben
authors.initials: B
authors.lastname: Harris
authors.forename: Natasha
authors.initials: N
authors.lastname: Spencer
authors.forename: R
authors.initials: R
authors.lastname: Sean Morrison
mesh_terms: D000328:Adult; D000368:Aged; D000700:Analgesics / Q000627:therapeutic use; D001071:Appointments and Schedules; D004632:Emergency Medical Services / Q000458:organization & administration / Q000592:standards / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital / Q000458:organization & administration* / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D059408:Pain Management; D017064:Process Assessment, Health Care; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D014481:United States
chemical_list: D000700:Analgesics